#5: Gender Affirming Surgery
COMMUNITY VOICE: Lena | HEALTHCARE EXPERTS: Rachel Bluebond-Langner MD, Asa Radix, MD | COMMUNITY REVIEWER: Gaines Blasdel
SUGGESTED RESOURCES
These are by no means exhaustive, but are meant to be a starting point! Contact us if you’ve got anything to add and we’ll update this list periodically!
To navigate the insurance/legal logistics
Community Health Advocates: a group that provides free legal assistance to New York State residents navigating insurance issues, such as denials. Check your local zipcode or city for similar projects.
Trans Health Project: DIY guide to trans health insurance benefits.
Trans Family Support Services: network of parent-advocates
To learn about the surgical process
Some UCSF guides we like:
Finding providers
Callen Lorde’s TransAtlas - a way to find a trans-friendly provider
Confirm that your plastic surgeon is board certified here
The Gender Affirming Letter Access Project: a group of providers across the US offering pro-bono mental health letters of support as harm reduction practice.
SHOW NOTES
Note
We reference body parts by their anatomical terms for clarity of meaning. However, we recognize that folks choose to label their bodies in different ways.
Overview:
What is gender affirming surgery? (associated links: here, and here)
A range of surgeries that includes the removal or addition of breast or chest tissue, creating a vagina and labia, creating penile tissue, or creating a penis. A gender affirming hysterectomy is also possible. Don’t forget facial surgeries!
The most common ones are chest and facial surgeries, but given the difficulty in accessing genital surgeries we talk about those a little more here
Ok, fine, some specific definitions:
Vaginoplasty: The formation or creation of a vagina or neo-vagina.
Metoidioplasty: from the Greek meaning “towards male genitalia,” this procedure can be done a number of ways, but involve the release of ligaments to lengthen the existing clitoral tissue that has often been enlarged by the prior use of testosterone, to form a small phallus about the size of one’s thumb.
Mastectomy: technically a term for the removal of breast tissue, many transmasculine and non-binary folks elect to have the partal removal of breast tissue to eliminate the appearance of having breasts or the creation of a more masculine or androgynous chest. Typically some breast tissue remains after surgery to provide the best cosmetic result.
Pre-surgery:
First up: information gather
Online forums are great! But buyers beware...bias. It's still an online review forum, so now that its biased in who chooses to participate in online forums or share pictures there
Surgeon’s website, realizing that they only choose the best photos, are also a good place
Look for folks with similar bodies and skin colors to hear their stories
Find a good primary care doctor
Primary care providers will help navigate any possible changes in hormones post-op and be there to set you up with any resources for possible post-op stress or depression
In addition: surgery stresses your body! A PCP can find ways to get your medical care in a good place before surgery to make the recovery process as smooth as possible
E.g. having your blood pressure, cholesterol, and/or diabetes optimized
Also, quitting smoking. Many surgeons will do a lab test to see if someone is smoking. Called cotinine testing, it's a breakdown product of nicotine and tells the health care provider if someone recently smoked nicotine.
FYI: there is some data that suggests folks who had access to primary care prior to beginning or completing puberty, including hormone blockers are less likely to get surgery
This is because the tissues they want surgically modified never developed
For example, someone who took hormone blockers never developed breast tissue so never gets breast tissue removed surgically
Find a surgeon
Where to look?
For some folks, the internet is a great starting point
Others will be able to receive referrals from PCPs
Some things to look for regardless of where you find your surgeon:
Make sure they are board certified (if it’s a plastic surgeon you can do so at this website)
Someone with experience providing these procedures to trans individuals.
A mastectomy for breast cancer is not the same as a gender affirming mastectomy - different techniques and different goals
Dr. Radix’s hot take: it’s ok to be on a surgeon’s wait list if that means they have more experience
Do they take your insurance?
Hair removal! If this is relevant to the surgery being planned.
Get a head start - it often requires upwards of 10 sessions and takes about a year
Look for folks who have experience in clients with your level of melanin
What kind of hair removal?
Laser hair removal: A process using laser to target hair at the root (works best with dark hair on light skin)
Electrolysis: A process targeting individual hairs with a light electric current (either by heat or a chemical reaction) to remove individual hairs (may be more likely to work with light blond hairs on light skin, dark hair on dark skin, or grey hairs regardless of skin tone).
Getting mental health providers to provide a letter for your insurance clearance
Let’s start out by saying:
This is a controversial barrier to care that is often seen as a transphobic and discriminatory gate-keeping measure (almost no other surgery requires this step)
...but, if someone is making you see a mental health provider know that surgery is stressful and there are real resources a mental health provider can offer
Heads up: this can take a while
Double heads up: if you are having bottom surgery you will almost certainly need TWO different mental health provider letters
Submit your mental health letters to your surgeon, who submits them to insurance
Hours of hold music
If insurance says no, there are multiple steps a surgeon can take to appeal
Post-surgery
Set expectations
Post-op depression is common! It's not unusual that with big changes and the physical stress to experience changes in mood in unexpected ways
There is a healing process. It can take months, depending on which surgery you have
Your physical comfort and activity level will take time to return to baseline
Seek out caregivers before hand to help you afterwards
Dilation (this is relevant only to vaginoplasty)
Dilation is done to maintain depth and width in a newly constructed vagina
Expect to dilate weekly throughout your lifetime in order to have receptive vaginal intercourse
To that point - not everyone will share a goal of keeping an open vaginal canal. If that’s the case for you, we encourage you to check in with your healthcare provider about what this means re:dilation
Helps with healing, pain, urinary issues, dilation - a win!
Ask your surgeon for someone who has worked with people who have had your surgery before you, and who will be affirming!
Is totally defined by the person experiencing it, and different folks will have different goals for their own sexual satisfaction
Lubrication
Self-lubricating may not, on its own, be enough lubrication to make penetrative sex feel comfortable
Lubrication tied to arousal is unlikely - ask your surgeon blunt questions about what to expect and what is a possibility
Orgasm - can take time, practice, and getting to know your new body. Again - ask your surgeon honest questions!
If you use the body part for sex, get it tested for STIs
Hormones may change - it really depends on the surgery, so talk to your provider
If you stop hormones or no longer produce them (like after having testes or ovaries removed), think about bone health long term
Heads up: stopping hormones may add to post-op mood changes
Some final context:
To quote Lena (our community voice for this episode): having surgery is not everyone’s end goal. Everyone’s journey with any gender affirming medical care is their own!
TRANSCRIPT
Lena: I knew that I wanted to have surgery. Did I know how it was going to happen? - No. I started to do more and more research about everything because I had already identified as being trans or a person of trans experience. And it just made more sense for me to become whole with my body.
[QHP THEME MUSIC]
Gaby: Welcome to QHP. QHP is a podcast about queer health topics for sexual and gender minorities. My name is Gaby. I use she/her pronouns and I am in primary care internal medicine training in New York City.
Sam: I'm Sam, my pronouns are he/him. And as per usual, I have the same job title as Gaby.
Richard: And I'm Richard. I use he/him pronouns and I'm the medical director of the Pride Health Center at Bellevue Hospital in New York. And I work with Sam and Gaby.
Gaby: At the top of this episode, we heard from Lena, who's going to be sharing her experience with gender affirming surgery.
Richard: And though this podcast is about gender affirming surgery, we're not going to be able to talk about everything involved in about half an hour.
Sam: We won't be discussing the technical aspects of gender affirming surgery this episode. Like how the operation itself has done. Instead, Lena and our healthcare expert voices are going to talk about navigating the process of finding a surgeon, the paperwork –
Gaby: – and there is so much paperwork –
Sam: – and some advice for the recovery period.
Gaby: So we keep saying gender affirming surgery, but I want us to get specific. So maybe there's an old wise queer doctor who could enlighten us…?
Richard: I think you mean me and I'm not really that old, even though I keep joking about it. So people often talk about quote, unquote, “the surgery” as if there's only one surgery and everybody wants it. But commonly known as top or bottom surgeries, we refer to gender affirming surgery as any surgical procedure that's done with the intent of aligning someone's self-understanding and their physical body.
Gaby: And so to put it in a little bit more specific terms, gender affirming surgery describes a range of different surgeries, including the removal or addition of breast or chest tissue, creating a vagina and labia from tissue that was a scrotum or penis and a group of surgeries that can be used to create a penis from existing genital tissue.
Sam: We should note for clarity of understanding throughout this episode, we'll be referencing body parts by their anatomic terms, but we realize that folks may choose to label their bodies in very different ways.
Richard: Regardless of the type of procedure or surgery, everyone's experience will be very much their own. Our goal is to create some general guideposts through a maze that is accessing gender affirming surgery as a healthcare service.
Gaby: And before we really get into it, an important acknowledgement: we, which means me, Sam and Richard are all cisgender. We tried to center this episode on trans voices, but it's also worth noting that there are tons of resources out there that are trans run, like online groups and forums where similar information is available. We're going to link to a bunch of it in our show notes. But our goal right now on this episode and the next 30 minutes is to take what's known about queer health - a lot of it actually raised and organized by trans communities - and make it more available and accessible.
Sam: But mostly paperwork.
[TRANSITION MUSIC]
Lena: My name is Lena. I'm a junior in college, my pronouns are she and hers. I'm studying political Science and German Language. Hopefully [laughs] down the line I could become a diplomat.
Gaby: So I'm just going to go ahead and say that if Lena can navigate getting gender affirming surgery, then she definitely has the skills and patience for a very storied career as a diplomat.
Sam: And I won't go into my storied career as a diplomat because...I haven't had one. But here's Lena on when she knew gender affirming surgery was on the horizon for her:
Lena: I knew that I was not cisgender from a very early age [sound of nails tapping] and I knew that I wanted to have surgery. Did I know how it was going to happen now? Around like 15, 16, that's like when I was introduced to being trans. I knew how I felt, but I didn't even know the word for it. And it just made more sense for me to become whole with my body. So surgery was always a must for me.
Richard: For some folks, gender affirming surgery is not part of their transition for others. For Lena, it's a really critical component. And then there's lots of folks who are somewhere in between the two. As always, these decisions are entirely individual.
Sam: Once Lena started thinking seriously about surgery. She turned to everyone's favorite healthcare provider – the internet – to get more information. As many do, she dug into the online forums where trans individuals share their experiences around surgery.
Lena: I read the forums, but I did not ask my questions in the forums. I was more into YouTube cause I'm a visual person, so definitely YouTube helped a lot.
Gaby: There are a lot of different forms out there for folks who are looking to learn more about bottom surgery. Some focus on navigating the process but there are others (like the ones that Lena was just referring to) that include post-op photos, and they can actually be really helpful to learn what kinds of surgeries are out there and which kinds of techniques you might be interested in pursuing.
Richard: And also we should pause to appreciate how impressive the trans community is at networking this information. Historically, these types of forums haven't been really available as an option.
Sam: Historically meaning pre-internet, and not just when Richard still had hair.
Richard: You assume I had hair when the internet came out?
Gaby: This episode, sponsored by Rogaine. [Richard laughing] Just kidding. This episode sponsored by caffeine that I bought myself because no one pays me to do this and I am chronically tired.
Richard: These online forums are a testament to gender affirming surgeries’ marginalization within healthcare, which is changing, but remains politically charged and often hard to access.
Gaby: I'll admit, I don't usually tell my patients to Google it when I'm giving them advice in clinic. But when it comes to gender affirming surgery, our healthcare experts actually seem to think that this was a really legitimate starting point.
Dr. Asa Radix: I'm Asa Radix, I'm a physician, and for probably the last 20 years I've been working with trans and gender diverse people as they've been navigating their way through either hormones or gender affirming surgeries.
Richard: Dr. Radix also appears to have mastered the humble introduction. What he left out is that he's the director of education and research at Callen Lorde, a community health center here in New York. And co-chairs the WPATH, World Professional Association of Transgender Health Standards of Care Eight Committee and casually finished his PhD while all this was happening.
Gaby: Here's Dr. Radix on Dr. Google.
Dr. Asa Radix: There are also a lot of resources on community websites. You know, they’re Facebook groups for people who are interested in top or bottom surgeries. Also the surgeons websites, many of the surgeons who do this work put a lot of money information on their websites. And I always think it's a really, really good place to go to look for information.
Sam: So – where you are sourcing your information from matters.
Dr. Asa Radix: Remember that surgeons and never going to post the photos, if they're not good. So If you want realistic photos of like before and after shots, try some of the Facebook groups where people share their before and after photos. I think it's always good to try and find someone who had top surgery. Who's kind of like your body size and maybe, has the same coloring as you have. And then you can get a better idea about what it's going to look like.
Gaby: And this is actually a strength of the world wide web, which is being able to find photos of other people with your body type, skin color, and similar age ranges. Because as is true literally everywhere, representation matters.
Lena: When it comes to the surgery, that's such a, um, a gap on who actually gets it. I don't really see a lot of people around my age that are having bottom surgery. I see a lot more older women and our health is in two different places. So I tried to find people on YouTube who both look like me and didn't look like me.
Sam: So like anything on the world's widest web, make sure you are taking everything with a bit of a grain of salt. But before we get any deeper into this episode, there are a lot of different surgeries that might fall under the umbrella of gender affirming surgeries. So we're going to give you an overview that neatly lays them out.
Richard: The main surgeries that we're going to be talking about are vaginoplasty, which is the creation of a new or neovagina from other structures. Phalloplasty, which is the creation of a penis or neophallus using local structures and skin grafting usually from the arm or the thigh. This usually occurs between two to four different stages. And the last is metoidioplasty, a procedure to release and lengthen the clitoris that can sometimes, but not always, allow for the owner to penetrate a partner.
Sam: And with that I think we're ready to talk about the next steps
[TRANSITION MUSIC]
Gaby: So let's say that you've explored the forums. You've looked at some pictures, you have a pretty good feeling that bottom surgery’s something you want to pursue. What comes next?
Sam: We should let you know that we are all three primary care doctors. So our first answer would be...talk to your primary care doctor.
Richard: Okay. So here's my plug. A good primary care provider can get to know you as a whole person, including your values and preferences and help guide you as someone with a holistic view of your health. Surgery can be really stressful on your body. And if things that can impact your heart health, like your blood pressure, your cholesterol, or diabetes can be better controlled. It's great to get that done before surgery so that your post-op healing process can be that much smoother. When preparing for any kind of surgery, we think about things like what medications you're taking and if any of them need to be adjusted or stopped before surgery, are you on the best medications and the right doses?
Gaby: And in addition to that, we spend a lot of time thinking about smoking cessation.
Sam: So you may have not had to ask Dr. Google, but smoking is not good for your health - and for many different reasons.
Richard: For those planning to undergo surgery, smoking is harmful because it increases the risk of bad things happening to your heart. And even more so, most surgeons believe that it can impact healing enough to worsen the outcomes of your surgery.
Gaby: Apart from physical health, we spend a lot of time as PCPs thinking about your mental health, because it's something we consider a really crucial component of overall health and plays a big role in gender affirming surgery.
Richard: Absolutely - people feel a wide range of emotions and experience new and different ways of moving through the world after gender affirming procedures.
Gaby: And if receiving gender affirming hormones for a while through your PCP, it may actually be the case that you may or may not pursue surgery.
Richard: If someone has had good longitudinal primary care and through it, early access to hormone blockers, they may not develop secondary sex characteristics as a result. They may be living in a body that feels really comfortable for them, and they may not feel they need surgery. It's normal for people's desire for surgical or really any gender affirmation to change throughout their lifespan. And what's affirming at one point in time may be different than another stage of life.
Lena: I came out at 15. I did not start taking hormone replacement therapy until 18, but if I could have came out sooner, I would've. I feel like it would've saved me a lot more discomfort and dysphoria within my life. I wouldn't have gone through these hormone and genetically male secondary characteristics. I could have avoided all of that. The up and coming younger generation growing up in the early two thousands - the youth are coming out earlier and earlier.
Sam: Oh, Gen Z envy. Does it know no bounds?
Richard: That TikTok looks much more fun than the MySpace.
Sam: Sorry, Richard, do you know what you're saying?
Richard: Not really...
Gaby: Okay, where we're unraveling a little bit. So let's just round this primary care section up by saying that we acknowledge that not all folks who are listening are going to have access to a PCP with whom they can talk about gender affirming surgery. And so the point of our spiel here is just to say, preparation for surgery can begin with your general health. If it's something that you were thinking about and that you're open to.
[TRANSITION MUSIC]
Gaby: Okay. So with this lead up I think it's safe to say that it's time to make moves. And by moves I mean start to look for a surgeon. But the question is –how?
Richard: Folks will get referrals from their PCPs and others will turn to my sometimes-nemesis, Dr. Google, to get a sense of their options.
Gaby: But the internet is an overwhelming place.
Sam: Especially for Richard. [laughter] Sorry, Richard. [laughter] Just kidding.
Gaby: I mean, it's not just Richard. I had to delete TikTok off my phone because lesbian TikTok was consuming all of my free time and interfering with my life. So anyway, my point remains, how do you start to narrow down your Google search results if you're starting with the internet to look for a surgeon?
Sam: Let's ask a gender affirming surgeon.
Dr. Bluebond-Langner: I'm Dr. Bluebond-Langner. I'm a plastic surgeon at NYU Langone. I am the Laura and Isaac Perlmutter Associate Professor of Plastic and Reconstructive Surgery, and my practice is dedicated to gender affirming surgery. So I think you want somebody who is board certified in their field, who has extensive reconstructive experience, who is open to a multidisciplinary approach from different specialties. And I think who also has experience and extensive exposure doing gender affirming surgeries, specifically vaginoplasty, phalloplasty, and metoidioplasty.
Richard: Regardless of surgical subspecialty, there's one important thing to look for: experience in working with trans folks.
Dr. Asa Radix: There's a lot of variation, for example, in the quality of work and also the surgeon's knowledge about trans communities. So like a surgeon who's qualified to do mastectomies or, you know, breast removal in cisgender women who maybe have, you know, a diagnosis of breast cancer - they might not actually have the skills to do top surgery in transmasculine folk because the, you know, the purpose of the surgery and the techniques are different.
Richard: So you're looking for number of years on the job and also numbers of this specific surgery that you're looking for having been done. And when possible, a willingness to recruit others to help get the job done.
Gaby: That covers all the technical stuff, all of the on-paper stuff, but that's not all there is when you're thinking about who to pick for a surgeon. And I know this is going to sound so classic lesbian of me, but what about the chemistry? That's important too.
Lena: I knew that I wanted to go to a surgeon who I was comfortable with and I knew that would be comfortable with me - just mutual comfortability between the two. And I had went to another consultation before and I wasn't really sold on, um, them. I had nothing against them I just wasn't really sold. It's a lot deeper than people think it is. It's not just aesthetic.Iit's function and all that stuff.
Gaby: What Lena talking about is important with any healthcare provider, which is making sure you feel safe and comfortable.
[TRANSITION MUSIC]
Richard: Choosing a gender affirming surgeon is a key part of the process. But there's a lot of stuff that comes after choosing a gender firming surgeon and before undergoing the actual procedure.
Sam: Like any encounter with healthcare, there's a lot of paperwork. And in this case, one really important aspect of the paperwork is making sure that the surgeon accepts your insurance.
Gaby: But even before the redundant forms at the office, gender affirming surgery has an additional hurdle to jump.
Gaby: These letters aren't popular among patients or the hosts of this podcast.
Sam: And to Lena.
Lena: So first of all, all of those are horrible. The process is so dreading and long. If your therapist or psychiatrist doesn't think that you're ready, they will keep you from, like, having surgery. It’s only, if they've truly believe that you are ready, fit both mentally, physically, and emotionally ready for this (nails tapping) life changing surgery, but you'll get your letters.
Sam: Hot take: the model of approval used for gender affirming surgery is inconsistent with other models for surgical procedures. The majority of procedures, irreversible or not simply require informed consent, meaning a discussion of the risks and benefits with the patient. In it's exception for gender affirming surgeries. It is inherently discriminatory and a form of transphobic, paternalistic medicine that insurance requires a mental health provider to sign off on some of these surgeries.
Gaby: And while it's insurance that requires these mental health letters. Dr. Bluebond-Langner’s clinic does use this as an opportunity for multidisciplinary support to deal with some of the stressful logistics of undergoing a major surgery.
Dr. Bluebond-Langner: These...can definitely feel like gatekeeping measures. The hope is that we can help you find somebody who can talk to you, not about your gender dysphoria, but really more about what this process is going to entail.
Sam: While insurance companies requiring a letter from a mental health provider can be a barrier to care, it is an opportunity to utilize the resources that having to see a mental health provider can provide. That said, this still isn't an endorsement from us or the healthcare providers that we spoke to that the mental health letter should be a required part of the process for accessing gender affirming surgery.
Richard: And then once you have the letters, then the paperwork shuffle just moves into the surgeon's court.
Dr. Bluebond-Langner: We submit to the insurance company and we get an authorization, right. Or an approval. There are occasions when the insurance company will deny the procedure. Maybe the patients under age or certain criteria in their mind, in the, in the eyes of the insurance company haven't been met. At that point we do what's called a peer to peer. And so I make a phone call to the insurance company. I speak to another physician there. If again, we're denied, we then go through an appeals process. So we appeal, and often we'll get lawyers involved. So perhaps it's advocating for the employer to change their benefits coverage for the insurance plan to relook at this case through a different lens.
Sam: Ooof, the “I” word. Didn't they just reboot that show?
Gaby: No, that's the L word and hot take: I think the original is so much better than the reboot, but I digress. We're talking about insurance here.
Sam: Dr. Bluebond-Langner is pointing out that even once the individual pursuing surgery has taken the time, the money, and the work to get a letter from a mental health care provider, the surgeon, assuming they have found a surgeon, still has to submit all of this paperwork and hope it's approved by insurance.
Richard: And if not, they have to go through the time consuming and exasperating process, not to mention surgery-delaying process, of appealing. Our community reviewer also pointed out how each state has different insurance laws. So add the variability and insurance and state laws to the mix, and you've got…
Sam: …a clusterfuck?
Richard: I was gonna say multiple compounding barriers to care, but yeah, a total fucking clusterfuck.
Gaby: And while we're talking about barriers to care, let's also name the fact that there are insurance companies out there who are looking for reasons not to approve these surgeries on the grounds that they're only, quote, “cosmetic”.
Richard: Gender affirming surgeries are absolutely not cosmetic. There are cosmetic changes that happen during the procedures, but they're done to align identity and body.
Gaby: And that has profound impact on mental and physical health. And if you don't believe me, here's Dr. Radix.
Dr. Asa Radix: Overwhelmingly, having access to these surgeries improves quality of life and improves happiness, improves, you know, improves people's mood. There's so many, so many positives.
Richard: A recent review of how quality of life, body image, gender dysphoria, depression, anxiety, and overall psychological health compared before and after the surgery - literally all of these factors improved after surgery.
Sam: [sounds of paperwork shuffling] Let's recap the paperwork shuffle
Richard: If you have a primary care provider, start with them, make sure that your hormones are optimized prior to your gender affirming surgery. Then find a surgeon, find a mental health provider. If you're having bottom surgery, find a second mental health provider.
Gaby: Then your surgeon submits the paperwork, insurance reviews it. And for the sake of sanity and moving along to our next section, let's say your surgery is approved! (Sam makes mouth trumpet noise) All right. So 1 million calls to insurance later and surgeries approved, and Sam makes trumpet noises for you personally with his mouth.
Sam: And in our comments, please link to your favorite hold music from insurance companies, and we'll make a Spotify playlist for you. Just kidding. For gender affirming surgeries involving genitals, a surgeon may require a healthcare consumer to get hair removal.
Richard: By hair removal, we aren't talking about waxing or shaving. We mean laser hair removal that will ensure that no hair will grow on the areas of skin that may be moved during surgery.
Gaby: Lena got hair removal. So let's listen to her talk about it.
Lena: I did about maybe like 10 to 12 rounds of laser hair removal before surgery. Just to like decrease as much hair down there as possible. It's not pleasurable it's...at this point, it's a necessity. You have to do it for surgery. But the end result will be perfect because then you won't have hair growing inside the vagina, which could happen if you don’t do it.
Sam: Lena hits upon the reason why hair removal is sometimes required. In short: post-op complications. Hair that grows inside neovaginas can cause skin breakdown, infections, and discomfort. And for certain neophalluses, depending on the technique that's used to make it, hair can cause a buildup that may block urinary flow.
Gaby: It's also worth noting that, presumably because of all of those complications that Sam just listed, the studies on this suggests that post-op satisfaction rates are higher when folks get hair removal prior to surgery.
Sam: Hair removal can take around up to a year to complete the entire process. That's because hair grows in cycles and you need to hit it at the right time to get rid of it. We also wanted to point out that folks with different hair colors, like blonde or gray hair, will have a slightly different process to expect. And people of color or anyone with more melanin in their skin will likely want to look for providers who have hair removal experience in individuals with similar skin pigmentation. Check out our show notes for more information on the specifics of hair removal.
[TRANSITION MUSIC]
Richard: We've spent a lot of time talking about the lead up to surgery, but I'd expect a lot of folks who are interested in hearing about the recovery process.
Sam: Everyone we interviewed had a pretty clear message: expect a healing process.
Dr. Asa Radix: If someone's having a, you know, a complex bottom surgery, you know, it can be months before, you know, the swelling has all gone away and that you're able to kind of get around the way you did before. But you know, for- for most top surgeries, people are really back to their usual routines within, you know, a week or two. Although, you know, they still may have some restrictions about lifting or, you know, like some surgeons don't want people who've had top surgery to like sleep on, sleep on their belly, for example.
Richard: I want to emphasize something. It can be weeks to months before folks feel back to their regular level of physical comfort and activity. And we're talking about fatigue, not just pain or use of the new body part. For that reason, we want to really encourage that people undergoing surgery seek out post-op support from their friends, family, or larger community.
Sam: For Lena having the right caregiver at her side, in this case, her brother was really important.
Lena: Definitely have a strong support system that you trust. Um, someone who's willing to get their hands dirty. Cause you bleed a lot [laughter]. You have to be with someone who's comfortable enough to help you out. I'm the strong friend. So allowing myself to be vulnerable with people during this time of need, like, I need something and I can't get it myself. I have to voice out to other people.
Richard: And major surgeries can be a catalyst for having some depression post-op. You're feeling more fatigued. Your body is really exhausted. You've had changes to your body and.or the way that you can move through the world. It's not surprising to feel down even after surgery that someone's been eager and hopeful for for years.
Gaby: And that's just another reason to seek out support systems. But I think the important thing when you're talking to your caregivers is to actually be able to fill them in on what the recovery process specifically looks like. So we've got Dr. Bluebond-Langner here walking us through what kinds of recovery protocols exist for each of the gender affirming surgeries that she performs.
Dr. Bluebond-Langner: For phalloplasty, again, we keep patients in the hospital for about five days. Those patients are on bed rest for the first few days, which is challenging. They do leave the hospital walking and not really on any kind of narcotic. A little bit of Tylenol and ibuprofen. But mobility can, can be limited, especially in the first three to six weeks. So again, we recommend taking that time to focus on your recovery and healing and time off from work.
Sam: Everyone's healing time is going to vary. And some bodies may have different recovery periods and pain reactions to the same procedure. A quote, “minor” surgery is still a surgery. So any recovery period should expect a healing process and some pain.
Gaby: True. Okay. So we covered phalloplasty. Let's listen to Dr. Bluebond-Langner discuss the vaginoplasty recovery, specifically dilation.
Dr. Bluebond-Langner: The challenging part is the dilation. So that is something that you do four times a day for 15 minutes at a time, and has to be done in a private space. It can be challenging at first, as you sort of learn and navigate, perhaps you're sore as well. So we always record that the patient's allot six weeks off of work to really focus on the dilation, focus on the recovery, and not have to worry about other things
Richard: During healing the body tries to heal what was done during surgery. And in doing this, people can lose depth or width of their new vagina, and dilators help to prevent this from happening. As the body goes through the stages of healing, the dilators will help to stretch the tissue. Another resource for postoperative healing and recovery is pelvic floor physical therapy. Gotta love a physical therapist. Not only can targeting the pelvic muscles for physical rehabilitation help with pain. It can also address issues with difficult dilations, addressing issues of pain with penetrative sex, and also address issues with peeing.
Gaby: This postoperative healing process – dilation, maybe physical therapy – it can be a lot to adjust to. Here's Lena talking about her process.
Lena: It's just uncomfortable. Especially in the very beginning. Like when I got released, like after I would dilate, it would feel like the dilator is still in me. Sleeping on your back. If you're not a back sleeper - also comfortable. So it's just like little things. It's little things like that. But after a while, you can go back to sleeping on your side. Dilation becomes easier, you just have to be consistent and that's something that they tell you to do. And you move at your own pace with the dilators. You’re not going to just go straight from surgery and just go straight to the last dilator.
Gaby: Okay. So it's not just post-op pain. There's a lot more to the post-op picture.
Sam: Our community reviewer pointed out that folks should expect to dilate weekly if – if – they want to maintain a vaginal canal.
Richard: And of course, some folks may not dilate and knowingly allow their canals to close - which gets us back to Dr. Radix’s point about sexual satisfaction.
Dr. Asa Radix: You know, there, there's so many different ways to look at satisfaction and I think it really comes down to what someone's goals are. And what their priorities are, right? Because you know, you can look at aesthetics. So what does something look like? And you can also look at things like a sensation. You can look at pleasure. You know, is someone able to orgasm? Those are all things that we, you know, that all kind of fall under satisfaction.
Sam: Long story short: post-op sexual satisfaction looks different for everyone.
Gaby: But unsurprisingly it's on the minds of a lot of folks who are getting gender affirming surgery.
Dr. Bluebond-Langner: It 100% comes up preop and postop, and it is incredibly important to us as surgeons, for patients to have a satisfying sex life, um, and that they're able to orgasm. And to that end, orgasm is complex. So we are very careful in the operation to make sure the technical components of sensation are maintained, preserved.
Gaby: But at the end of the day, sexual satisfaction is not just about the hardware.
Dr. Bluebond-Langner: It's a mind-body connection. And so post-op work with patients to explore their new anatomy, and sort of reengage with a part of their body that perhaps was not pleasurable prior to surgery.
Richard: And for that reason, it's super important to spend time talking to your surgeon about your expectations for your new post-op parts. Don't be shy about asking about the new apartment’s plumbing.
Gaby: Dr. Bluebond-Langner mentions that there's a procedure called a peritoneal flap, which may be part of the vaginoplasty process that can provide some lubrication.
Dr. Bluebond-Langner: But a lot of people will ask us as a self-lubricating vagina and self lubrication is a very complex phenomenon. It has to occur at the right time, in the right place, and in response to sexual arousal. And so while the peritoneum may provide some moisture and some lubrication - is it enough lubrication for receptive intercourse? Iis it in the right spot? And does it occur at the right time?
Richard: Peritoneal flaps will provide a baseline level of lubrication, but it may not be enough for lubrication during sex. It also will be disconnected from the arousal response. So folks who are expecting a self-lubricating vagina or to pre-cum or ejaculate, or have orgasms should have frank conversations with their surgeon about what they should expect.
Dr. Bluebond-Langner: I have some patients, I think, orgasm within the first week. fFr some patients it really takes practice and perhaps learning new techniques for masturbation or achieving an orgasm with a partner.
Richard: in some ways the counseling on this is similar to what I tell other patients. Orgasming takes work and expectations are important.
Gaby: And since we're talking about sex, if you're using a body part for sex - test it for STIs. Dr. Radix’s research suggests that folks with neovaginas are prone to chlamydia infections. It's not clear whether they're just as prone as other people or more prone. But generally our point is if you've got it and you're using it, then test it.
[TRANSITION MUSIC]
Gaby: All right. One last aspect of post-op care that we want to bring up is hormone therapy. Dr. Radix gives us his take.
Dr. Asa Radix: I mean – it's always centered on, a person's goals. But in general, for someone who's on, hormones, you know, they’re usually stopped - not always, but, generally, if - if they're stopped, they can be restarted within a week or so. Often even sooner. The thing is that if you've had what we call gonadectomy (so if the testes are removed, or, if a trans masculine person, for example, has the ovaries removed) they now, they're not making their own hormones. So the thing is that if you, for example, decide that you do not want to be on testosterone or estrogen that you were taking, there is a risk of bone loss. Because, you know, sex steroids, you know, the sex hormones do help to keep the bones intact. So you could end up with what we call osteopenia or osteoporosis. So really a weakening of the bone structure, which isn't, isn't a good thing. There's no definite recommendation of one way or the other, it's really up to the client.
Richard: Long story short: depending on what procedures you undergo, it's possible you can stop taking some of your pre-op hormones. If you do, it might trigger some post-operative depression or some loss of energy. And in the long-term being off sex steroids could put you at risk for some secondary effects, like bone loss. You should definitely speak to your provider about those.
Gaby: So this is another plug for getting connected with primary care. Pre-op, our hope is that your PCP can facilitate a conversation about risks and benefits of continuing or not continuing the hormones that you'd previously been on. Because ultimately there are no hard and fast rules on this, and the decision is yours to make with the information to help you make it.
Lena: It's a process. You move at your own speed. Don't look at someone else's transition and be like, well, I don't look like her, or I don't look like him. They probably don't know that either. (laughter) And then beginning, it's a process move at your own speed. Don't compare yourself to other people because it's your transition.
Gaby: And with that as our springboard, let's very quickly recap.
Richard: This episode is all about setting expectations.
Sam: Expect paperwork, metaphorically, oppressive amounts, and literally oppressive. As many critics have pointed out about the mental health letters.
Gaby: Expect that insurance varies widely. And if you don't have insurance, but can afford the surgery out of pocket, you'll likely have less, but still a lot of paperwork. In a nutshell, make sure you have help.
Sam: And don't hate me for saying this, but [singing] sexual healing.
Gaby: Okay. Yes, I will accept the pun this time, because if any outcome of a gender affirming surgery is a new sexual organ, getting to orgasm or pleasure, however that is defined for you could take some practice.
Richard: I didn't plan on spending some time alone with your new body part. Think about masturbation in a new and different way to explore what's going on with your new body parts.
Gaby: In fact, can we recommend that for all of our patients?
Sam: Absolutely. But until then here's Lena with the last word:
Lena: having surgeries not everyone's end goal, it's your choice. It's what makes you comfortable. If you only want to get FFS [facial feminization surgery] and the rest of your body, you're completely fine with it - go ahead and do it. If you only want to get a breast augmentation and you don't want bottom surgery, go ahead and do it. If you want to get bottom surgery and nothing else, go ahead and do it. It's - it's you. This is your life. You have to live your life for you. Not for anyone else. If you don't want surgery or hormones at all, then don't do it. It doesn't make you any less of a woman or a man. It just makes you you.
[QHP THEME MUSIC]
Richard: QHP is a power sharing project that puts community stories and conversation with healthcare expertise to expand autonomy for sexual and gender minority folks.
Sam: Thank you to our community guest Lena and our other interviewees, Dr. Bluebond-Langner and Dr. Asa Radix. We'd also like to thank our community reviewer Gaines Blasdel.
Gaby: For information on the stuff we talked about in this episode, check out our website, www.queerhealthpod.com. It's going to have show notes, summarizing the essential points, and a lot more.
Sam: And not to still be my normal, desperate online presence, but leaving a review and subscribing to our podcast feed on Spotify or Apple does go a long way for us, and helping us find a larger audience to share this information.
Richard: Desperate has never looked better.
Gaby: And then social media reminder from your friendly millennial lesbian. If you like what you heard, give us a follow on Twitter or Instagram. Our handles there are @queerhealthpod and you can let us know what experts you want us to bring on in future episodes. We're planning season two. so your input is totally welcome.
Sam: Thank you to Lonnie Ginsburg for composing the music heard throughout this episode.
Richard: And as always opinions in this podcast are our own and do not represent the opinions of any of our affiliated institutions. And even though we're doctors, please don't use this podcast alone as medical advice, but instead consult with your own healthcare provider